Provider Demographics
NPI:1033565288
Name:BLANCO, JUAN JORGE (SA-C)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:JORGE
Last Name:BLANCO
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 NORTHINGTON DR
Mailing Address - Street 2:
Mailing Address - City:EAST AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14051-1725
Mailing Address - Country:US
Mailing Address - Phone:716-480-2996
Mailing Address - Fax:716-204-8990
Practice Address - Street 1:1540 MAPLE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-3647
Practice Address - Country:US
Practice Address - Phone:716-480-2996
Practice Address - Fax:716-204-8990
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY16-314246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant